Subsidiarity in Global Health Governance: 'Two Publics' and Defiance in the Global Fund’s Operations in Uganda
17 Pages Posted: 25 Jul 2013 Last revised: 5 Aug 2013
Date Written: July 24, 2013
In this paper we critically analyse one of the new global health institutions: The Global Fund to fight Aids Tuberculosis and Malaria (GFTAM). The GFTAM, as an international body, is novel because it doesn’t operate at the national level in the countries in which it disburses funds for the three major diseases it deals with. Instead, it disburses funds through Country Coordinating Mechanisms (CCMs) which are country-level multi-stakeholder partnerships charged with developing and submitting grant proposals to the GFTAM based on national priorities. After grant approval by the GFTAM, the CCMs then oversee implementation at the local level. We argue that the CCMS present a new form of subsidiary in global health governance.
The CCMs, as new subsidiaries, ensure that people from developing countries have an opportunity to effectively participate in international health assistance by ensuring that grants given, fit the local country needs. However, we argue that the massive corruption in some African countries that has permeated the grant process of the GFTAM can also be attributed to the autonomous function of CCMs as subsidiaries.
Using a case study of Uganda the paper uses systems theory to argue that CCMs are constantly creating new closed systems at the domestic level that do not defer to the GFTAM as the overarching global health governor. In this case, corruption can be perceived as a means of defiance by the subsidiary.
We analyse the nature of defiance using the postcolonial theory of ‘Two Publics’ in which the CCMs as autonomous bodies behave differently when dealing with the GFTAM and the local population. The civic public presented to the GFTAM is deferential during the grant process but the primordial public engages in ‘Parallel redistribution’ in defiance of the long term objectives of the Fund. Ultimately, we argue so called attempts to ‘redistribute’ are ultimately at the expense of the primordial public because they ignore effective health outcomes for the local population. This we believe highlights the importance of transparency and accountability in health financing.
Keywords: global public health, corruption, governance, subsidiarity
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